Provider Demographics
NPI:1922712355
Name:SHANKLE, SHANNON (DNP-ANESTHESIA, CRNA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:SHANKLE
Suffix:
Gender:F
Credentials:DNP-ANESTHESIA, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1423 SUWANNEE LN
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-8805
Mailing Address - Country:US
Mailing Address - Phone:318-272-6089
Mailing Address - Fax:
Practice Address - Street 1:2600 GREENWOOD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3908
Practice Address - Country:US
Practice Address - Phone:318-212-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA229131367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered